The State of Mental Illness
A survey of mental health and treatment in the U.S.
R
mental health
mental illness
United States
Introduction
In the past couple of years, during a global period of isolation, suffering, and uncertainty, mental health has increasingly become a concern for everyone. Poor mental health represents a host of massive issues in the United States:
Suicide, the most severe outcome of mental health challenges, is the second-leading cause of death among people aged 10-34. The importance of mental health cannot be overstated when it comes to saving lives.
It is extremely difficult to be treated for mental health challenges. The average delay between onset of mental illness symptoms and treatment is 11 years. While a diagnosis doesn’t cure any illnesses, it can be important psychologically, financially, and of course medically for patients who require treatment. It can mean the difference between a patient paying thousands per month for treatment and paying nothing.
In the US, more adults reported struggling with mental health or substance abuse than physical health – around 40% in 2020. There is a tremendous need for mental health care, and to solve this crisis we must learn about, advocate for, and fund treatment.
This project was started for a data science course I took in 2022. Using two national surveys, I contrast the reported rates of poor mental health in each state with the accessibility of general facility-based mental health care. Further, based on local indicators of poor mental health and substance abuse, I rank each state for its ability to serve the specific mental health needs of it’s population.
BRFSS
Physical and Mental Health
The Behavioral Risk Factor Surveillance System (BRFSS) is a survey conducted yearly by the CDC which contacts hundreds of thousands of residents across the U.S. for basic information on health-related behavior. The survey is weighted by demographic as to account for any sampling bias. Upwards of 200 data points can be collected from each participant, but I only use a few related to mental health and substance abuse.
Each participant was asked some simple questions:
“Now thinking about your physical health, which includes physical illness and injury, for how many days during the past 30 days was your physical health not good?”
“Now thinking about your mental health, which includes stress, depression, and problems with emotions, for how many days during the past 30 days was your mental health not good?”
Let’s look at he number of days per month that respondents had bad physical and mental health days. The responses are binned into groups, to keep
More people reported that they have more bad mental health days than bad physical health days.
For the purposes of this project, the population with “bad mental health” is defined as all respondents who had at least 14 (14+) bad mental health day per month.Why?
Those with more chronic debilitating mental health challenges are more likely to benefit from accessible facility-based mental health care. While those with minor mental health challenges may still benefit from psychotherapy, e.g. cognitive behavioral therapy, these kinds of mental health challenges are not typically the target of Mental Health Facilities (MHFs) and are often treated without admittance to a facility.
Drug Use
Drug use, and particularly drug abuse, is highly associated with mental illness. source. The BRFSS gives us a good overview of drug habits related to alcohol and tobacco.
Alcohol
Participants were asked these questions relating to alcohol use:
“Considering all types of alcoholic beverages, how many times during the past 30 days did you have 5 or more drinks for men or 4 or more drinks for women on an occasion?”
“During the past 30 days, on the days when you drank, about how many drinks did you drink on the average?”
Those with at least one occurrence are considered to have participated in binge drinking in the past month.
This map shows the average number of drinks-per-capita.
Many of the norther states lead this category.
Smoking
“Do you now smoke cigarettes every day, some days, or not at all?
The following plot shows the percentage of people that smoke.
Unlike the question regarding general mental health, the information available about drug use only fills in part of the picture of substance abuse that would be treated at Mental Health Facilities (MHFs).
However, looking at these legal source non-medical substances benefits us in two ways:
First, we don’t have to worry about any interference between the observed rates of drug use and the prescription of these drugs by MHFs. MHFs are not known to prescribe alcohol, tobacco, but do prescribe benzodiazepenes (Xanax, Vicodin) and amphetamines (Adderall) that result in higher rates of substance abuse.
Second, when the government collects data about any kind of illegal activity, it introduces response bias that may not yield accurate measures how many people participate in the illegal activity. The survey skirts around this by asking some questions about people the respondents live with (See Figure Appendix)
Healthcare
The cost of treatment is a huge barrier to many people seeking care. For all health-related visits, participants were asked:
“Was there a time in the past 12 months when you needed to see a doctor but could not because of cost?”
Treatment is especially difficult to afford if a patient doesn’t have any kind of healthcare.
“Do you have any kind of health care coverage, including health insurance, prepaid plans such as HMOs, or government plans such as Medicare, or Indian Health Service?”
Texas and some other southern states stand out here.
NMHSS
The National Mental Health Services Survey (NMHSS) is a survey of 12,197 Mental Health Facilities (MHFs) across the United States to collect information about patient demographics, treatment options, practices, and funding. This survey aims to be a complete list of all operating mental health treatment facilities within the U.S, including general hospitals with a specialized psychiatric unit, residential treatment centers, and community behavioral health clinics. For a more complete overview of this survey, consult the Data Section of the References.
We will use this survey to get some information about:
- the kinds of facilities that exist in each state
- the types of treatment options they offer and thus, what kind of population they serve
- the affordability of those treatments
- and other aspects that might hinder access and afordability of care.
Lets begin by looking at where these facilities are located. While we don’t have access to the precise location, we do know the state in which the facility operates.
As we should expect, California and New York have the most facilities by a substantial margin.
If we calculate the number of facilities on a per-capita basis according to the 2020 Census, the map looks different.
Due to other factors that may compound with each state’s population, its a good idea to keep the population in consideration.
In addition to the number facilities per capita, there are factors that might affect accessibilty of mental health care.
For example, a state may have a sufficient number of facilities, but:
There are no facilities that provide treatment specialized to the individual’s needs
The facility still uses outdated or harsh practices
The facility cannot offer treatment to that individual for legal reasons
All facilities are full
All facilities are too far away from the individual
Even if there is a facility nearby with available rooms and specialized treatment that satisfies all of the individual’s other needs, an individual may still forego treatment because they cannot afford the financial cost. There are many barriers to treatment that aren’t covered in this analysis
Let’s learn a little bit more about these facilities in each state.
Facility Type
The NMHSS receives data from many different kinds of facilities. Each facility specializes in a certain type of care, which has been classified into 12 types by the survey, and simplified into 7 similar types in the figure below.
Emergency Treatment Centers, which include Outpatient Mental Health Facilities and Partial/Day Hospitalization Facilities are not evenly distributed across states. They seem to be an important contributor to Maine’s high rate of facilities per capita, while Texas has hardly any Emergency Treatment Centers. Traumatic experiences are associated with more severe mental health conditions like PTSD, depression, and anxiety. These facilities provide the care patients will receive immediately after a traumatic experience, in many cases, suicide.
Community Centers also contribute to state differences, more so in states with smaller populations. Alaska, Wyoming, and Montana have many of these facilities per capita. Community Centers and Behavioral Health Clinics are a broad category, with some facilities providing 24-hour emergency services, day treatment, and treatment for chronic mental illness. These facilities are licences by their respective state mental health authority. They can also coordinate with physical health care providers to give holistic care for all the patient’s needs.
Facility Ownership
Across states, the majority of Mental Health Facilities are owned by private non-profits. These facilities are not as incentivized to increase profits as for-profit institutions, but seeking care at these facilities may be more challenging and less accommodating than public facilities.
Facility Operator
Among public facilities, the organization in charge of facility operation impacts who can receive care, who provides the care, and how good the care is.
The Department of Veterans Affairs operates quite a few publicly-owned facilities. While veterans are especially likely to develop mental illness and it is important that they receive care too, non-veterans don’t qualify for Veteran’s health benefits and therefore can’t receive care from facilities operated by the VA. This means that in states like South Dakota, Arkansas, New Hampshire, or Florida, the majority of public facilities in the state can’t serve the majority of the population.
In fact, South Dakota doesn’t have any public facilities that are open to the general population.
Cost
From the 2020 Behavioral Risk Factor Surveillance Survey, about 10% of people had to refuse medical care due to cost in the past 12 months, which translates to about 33 million people. Nationally, about 50% of facilities offer payment assistance to those who cannot afford to pay the full amount or those who cannot pay at all. Some facilities accept multiple forms of payment for treatment as well, including Medicare, Medicaid, welfare, the state mental health authority, or a state-financed insurance plan.
If the individual doesn’t have to pay the full amount, or is allowed to provide different methods of payment, the less likely an individual is to refuse care due to cost.
Wyoming, South Dakota, and Oklahoma have the highest percentage of facilities that offer payment assistance, but all states have at least one facility that offers payment assistance.
Supplemental Material
Marijuana Use
Only some BRFSS respondents were asked about their marijuana use, and many reported that they didn’t smoke. This resulted in missing data for some states, and so this was not included.
Living With
Participants were also asked:
"Did you live with anyone who was depressed, mentally ill, or suicidal?"
Although these questions don’t implicate the respondent directly, may be affected by the rate of cohabitation, and less than half of all states reported data, I think the results are still interesting, and may more accurately represent the level of mental illness in the region due to response bias.
Participants were also asked:
"Did you live with anyone who used illegal street drugs or who abused prescription medications?"
Based on the primary indicator of mental health gathered from the behavioral survey, the most chronic mental health difficulties seem to be mostly observed in tight geographic regions of the Midwest and in the South, in states like Kentucky, West Virginia, Arkansas, and Louisiana. Nevada also scored highly on this measure.
Signs of substance abuse seemed to be observed most often in the northern states, Wisconsin, Iowa, including Montana, Nebraska, and North Dakota.
While the results of the indirect questions highlighted Montana, Utah, and Kentucky as states of interest for substance abuse and mental health, the data is too incomplete to use further.
References
Data
The data used in this project comes from:
- The Behavioral Risk Factor Surveillance System 2020 (BRFSS)
- The National Mental Health Services Survey 2020 (NMHSS)
In addition, I used data on population from the U.S. Census Bureau 2020 for per-capita information.
Works Consulted
Substance Abuse and Mental Health Services Administration, National Mental Health Services Survey (N-MHSS): 2020. Data on Mental Health Treatment Facilities. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2021.
Packages
R Core Team (2022). R: A language and environment for statistical computing. R Foundation for Statistical Computing, Vienna, Austria. URL https://www.R-project.org/.
Wickham H, Averick M, Bryan J, Chang W, McGowan LD, François R, Grolemund G, Hayes A, Henry L, Hester J, Kuhn M, Pedersen TL, Miller E, Bache SM, Müller K, Ooms J, Robinson D, Seidel DP, Spinu V, Takahashi K, Vaughan D, Wilke C, Woo K, Yutani H (2019). “Welcome to the tidyverse.” Journal of Open Source Software, 4(43), 1686. doi: 10.21105/joss.01686 (URL: https://doi.org/10.21105/joss.01686).